TPC-Journal-V4-Issue3

The Professional Counselor \Volume 4, Issue 3 251 The third criterion in the DSM-5 is very similar to that of the previous edition, aside from one notable distinction. In the new DSM , the phrase “persistent lack of recognition” (APA, 2013a, p. 339) replaces “denial” (APA, 2000, p. 589) in describing the anorexic individual’s perspective on the risks posed by his or her underweight status. As with the change to criterion one, the result of this rewording is more value-neutral (like refusal , the word denial has negative connotations). The resulting criterion may also be more accurate, in that the focus is on an inability of the anorexic individual to recognize the inherent dangers of his or her condition, rather than a conscious repudiation of the truth. Although these small linguistic changes may not seem especially significant, the outcome is a set of criteria that is, on the whole, less stigmatizing. This is important because research indicates that many clinicians have negative biases toward individuals with eating disorders. This may be especially true in the case of those with AN, and the stigma appears to impact the availability of quality treatment for the disorder (Thompson-Brenner, Satir, Franko, & Herzog, 2012). The fourth criterion for AN, which appears in the previous edition, was removed altogether from the DSM- 5 , so that there are now only three criteria for a diagnosis of AN. This previous criterion, amenorrhea (the cessation of menstruation), applied only to females who had achieved menarche (APA, 2000). By definition, then, this criterion inherently excluded all males, as well as pre-pubertal and post-menopausal females. Also excluded were females taking hormonal contraceptives (APA, 2013b). The removal of amenorrhea therefore results in a more inclusive set of criteria, reflective of the APA’s (2013a) stated goal of avoiding “overly narrow” diagnostic categories (p. 12), which in the past have contributed to an excess of EDNOS diagnoses (Fairburn & Cooper, 2011; Machado et al., 2013). As in the DSM-IV-TR , the criteria for AN in the DSM-5 include specifiers of restricting or binge-eating/ purging types (APA, 2000, 2013a). The language in the new edition is similar to that of the previous edition, but clarifies that the specifier applies to the last 3 months (APA, 2013a), rather than the DSM-IV-TR ’s more vaguely stated “current episode” (APA, 2000, p. 589). This change is relevant because the empirical evidence indicates that crossover between subtypes is frequent (Eddy et al., 2008). The DSM-5 reflects this research, and the text in the manual cautions that because such crossover occurs, “subtype description should be used to describe current symptoms rather than longitudinal course” (APA, 2013a, p. 339). It may be worth noting that some in the field have concluded that these diagnostic subtypes of AN are not actually clinically relevant (e.g., Eddy et al., 2008), although clearly the DSM-5 does not reflect this thinking. Like other disorders in the DSM-5 , the diagnostic criteria for AN now include additional specifiers regarding remission status ( partial or full ) and severity (APA, 2013a). The remission specifier may be especially useful for clinicians working with individuals with eating disorders, AN in particular. For example, with regard to the weight criterion, an individual who reaches “normal” weight will no longer meet the full criteria for an AN diagnosis, but may still be struggling with other key components of the disorder (e.g., intense fear of weight gain). Such a scenario may be particularly likely with this disorder, especially because a change in weight status can be the result of outside intervention rather than internal motivation (Nicholls, Lynn, & Viner, 2011). Finally, the DSM-5 includes a severity specifier that uses the individual’s body mass index (BMI). There are three levels of severity: extreme (BMI < 15 kg/m 2 ), severe (BMI 15–15.99 kg/m 2 ), moderate (BMI 16–16.99 kg/m 2 ) and mild (BMI > 17 kg/m 2 ). As the manual states, the ranges are from the World Health Organization categories for thinness in adults. For children and adolescents, clinicians are encouraged to use the BMI percentiles. These levels of severity help indicate the clinical symptoms, the potential need for supervision and the degree of functional disability (APA, 2013a).